Healthcare Provider Details

I. General information

NPI: 1376384560
Provider Name (Legal Business Name): PROMISE HEALTHCARE NFP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/03/2024
Last Update Date: 06/03/2024
Certification Date: 06/03/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

819 BLOOMINGTON RD
CHAMPAIGN IL
61820-2101
US

IV. Provider business mailing address

819 BLOOMINGTON RD
CHAMPAIGN IL
61820-2101
US

V. Phone/Fax

Practice location:
  • Phone: 217-403-5403
  • Fax:
Mailing address:
  • Phone: 217-359-1558
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: JENNIFER HENRY
Title or Position: CEO
Credential:
Phone: 217-403-5401